Joint Committee On Health Care
JANUARY 8, 1997
Chaired by: Senator Marc Pacheco, Representative Harriette Chandler
Pain is a universal and timeless issue. As the Greek tragic dramatist Aeschylus noted: "Who except the gods can live time through forever without any pain?"
As we approach the threshold of the 21st century, the question of managing pain effectively remains unanswered. On the one hand, the ethical duty to relieve pain is well established. According to the Agency for Health Care Policy and Research: "The ethical obligation to manage pain and relieve the patient's suffering is at the core of a health care professional's commitment."
Yet, on the other hand, in mid-November 1995, the Study to Understand Prognosis and Preference for Outcomes and Risks of Treatments (SUPPORT), the $28 million project funded by the Robert Wood Johnson Foundation, found that half of patients who died in the hospital experienced moderate or severe pain at least half the time during their last three days of life. Despite aggressive efforts to improve communications among care givers, patients and families, the SUPPORT Project failed to improve the quality of dying.
The findings of the SUPPORT Project were confirmed by the personal experiences of Judith A. Dyer, an oncology and pain clinical nurse specialist at a major Boston teaching hospital, in her direct testimony before the Special Sub-Committee on Pain Management on November 28, 1995:
"Recently I lectured in a program on pain management to 42 hospice and long term facility nurses. Prior to lecturing, I asked how many people felt they were at a somewhat expert level of knowledge on pain management. Two raised their hands. When I asked how many were intermediate, none raised their hands. 40 out of 42 nurses ranked themselves at the novice level."
Problems with managing pain are pervasive according to a letter submitted in testimony by an obstetrician/gynecologist on the staff of a large teaching hospital in Worcester:
"This letter is to document a series of events that took place in November, 1994. I had a patient with terminal cervical cancer approximately 30 years old. She had decided to stop treatment and
rely on comfort measures until her death. Her pain control at the time was inadequate and it was decided by her physician to start using a long acting oral drug such as MS Contin. The patient had [a managed health care plan] and the only pharmacy that she could use was out of what she needed. Her family went to other pharmacies and found that [a local drug store] had everything that she required. Her insurance company denied approval at [this] pharmacy even though their pharmacy could not get her drugs for four days. At that time we offered the patient admittance to the hospital for pain control until she could have the supply she needed at home. The patient was disgusted with the system and demoralized to the point where she stated she just wanted to die. No one and not any patient's family should have to go through this."
[Jill M. Terrien M.D., Department of Obstetrics and Gynecology,
University of Massachusetts Medical Center, Letter to the Special Sub-Committee
on Pain Management (December 5, 1995)].
More recently the psycho-social effects of long term pain were exemplified in the case of a Massachusetts woman who sought a Dr. Kevorkian-aided suicide rather than endure pain any longer.
Origins of the Special Sub-Committee on the Management of Acute and Terminal Pain
Precisely because pain has such universal implications, the Massachusetts legislature established a commission in May 1993 to study how pain was managed in the Commonwealth. A generally accepted definition of pain management is the one supplied by the American Board of Anesthesiology:
"Pain management is the medical discipline concerned with the diagnosis and treatment of the entire range of painful disorders. Because of the vast scope of the field, pain management is often considered a multi-disciplinary subspecialty. The expertise of several disciplines is brought together in an effort to provide the maximum benefit to each patient. Although the care of patients is heavily influenced by the primary specialty of physicians who sub-specialize in pain management, each member of the pain treatment team understands the anatomical and physiological basis of pain perception, the psychological factors that modify the pain experience, and the basic principles of pain management."
The mission of the Pain Management Commission as set forth in 1993 was to examine different ways to treat acute and chronic pain in relation to the new advances in medicine and to explore the fiscal implications as well.
The original legislators chosen to co-chair the Commission were Senator Frederick E. Berry (D-Peabody) and Representative William Cass (D-Wakefield). June 1993 marked the expiration date of the commission. It was revitalized in 1995 as a subcommittee of the Joint Committee on Health Care and Senator Marc Pacheco (D-Taunton) with Representative Harriette L. Chandler (D-Worcester) named as co-chairpersons.
The five original members appointed to the commission by the Governor in 1993. continued to serve on the special subcommittee in 1995. They are (see expanded biographies in Supplement A): Daniel B. Carr, M.D., the Saltonstall Professor of Pain Research in the Departments of Anesthesia and Medicine at New England Medical Center and Tufts University School of Medicine and the Medical Director of its Pain Management Program; Jean A. Guveyan, R.N., M.S.N., C.S.-A.N.P. the Pain Management Nurse Specialist and Co-Director of the inpatient Pain Management Service at Beth Israel Hospital; Nancy Ridley, M.S., Assistant Commissioner for the Bureau of Health Quality Management, Massachusetts Department of Public Health; Raymond A. Smith, M.A., D. Phil, M.D., Chief of Anesthesia at AtlantiCare Medical Center; and Mildred L. White, R.N., B.S.N., a hospice nurse.
The original commission held a preliminary hearing at the State House in 1993 to hear testimony directly from physicians, pharmacists, nurses, hospices, health maintenance organizations, private insurance companies, and consumers who had personally experienced pain or had dealt with pain management. At that first hearing, Amy L. Shafer, Assistant Director of Pharmacy at the Beth Israel Hospital in Boston pointed out:
"As you are well aware, the treatment of pain is a component of nearly every hospital admission and most outpatient medical care. The task of the Commission is a needed examination of current practices in this extremely important and common aspect of health care."
[Amy L. Shafer, Letter to Chairmen and Members of the Commission (May 20, 1993)].
Mission Statement & Goals and Objectives
The newly reconstituted Special Sub-Committee on the Management of Acute and Terminal Pain developed as its mission statement: "To improve the management of pain of all types in the Commonwealth of Massachusetts." It also established the following goals and objectives:
- To launch a series of public hearings throughout the Commonwealth to secure information from individuals and representatives of organizations concerned with all aspects of pain control.
- To focus community attention and further promote education in the area of pain management.
- To provide consumers with educational materials that describe the major therapies for pain management as well as resources to obtain them.
- To provide health care providers and regulators with state and federal requirements and educational materials for the appropriate prescribing of controlled substances.
- To make recommendations for reforms to the regulatory boards and the Great and General Court which would improve the availability of appropriate pain management.
- To make recommendations to licensing and regulatory boards and educational institutions to help set standards of training in the area of pain management for students and practitioners in the fields of medicine, pharmacy and nursing.
- To foster and support diverse approaches to therapy which would be appropriate to the community clinic or hospital, tertiary hospital, hospice, or home care settings.
In accordance with the goals and objectives, a series of public hearings on pain management were held across the Commonwealth in 1995-1996. The Special Sub-Committee met in Springfield, Worcester, Lynn and Boston seeking the ideas and concerns of health care providers - both traditional and alternative, consumers and interested citizens of Massachusetts. More than 40 people gave written and oral testimony (see Supplement B).
In the course of the hearings, it became apparent that the majority of people who testified represented two types of pain management: 1) those experienced with short-term acute pain such as surgeons and anesthesiologists, and 2) those experienced with the pain of a terminal illness such as oncologists, hospice nurses, anesthesiologists, etc. For both types of pain, there are excellent outcomes from effective pain management.
Thus, in the course of the hearings, several distinct themes emerged from the testimony. Consumers and their families complained of their lack of rights as patients, their problems filling prescription including their inability to locate 24-hour pharmacies. Physicians expressed concern about the unfounded yet widespread fears of consumer addiction - even for terminal patients in hospices - and the possible threat of criminal charges being filed against them for violating state and federal drug laws. Pharmacists spoke of the lack of communication with doctors writing prescriptions, their own fears of robberies because of their inventories of certain drugs and their concerns about regulatory oversight. All voiced concern about reimbursement procedures, lack of education about pain management among all of the health care professionals as well as the general public, lack of licensing standards for pain management providers, and a number of obsolete pharmacy laws that served as barriers to effective pain management.
With the advantage of hindsight, it is apparent that virtually all of the testimony was given by individuals who saw pain (both acute and terminal) as a real problem that had good outcomes with effective pain management. What was expressed in a rather limited manner were the concerns of the average physician who "works in the trenches" with the patients who have long-term chronic pain and become addicted to their prescriptions. Frequently, these patients simultaneously see a number of practitioners in order to meet the medication needs of their addiction or to sell the excess drugs on the street. Pharmacists often have the same concerns in filling prescriptions for consumers with chronic pain who are being prescribed enormous quantities of certain medications. Unlike the practitioner for and the consumer with acute or terminal pain, who welcome the addition of a listing of 24-hour pharmacies, many druggists fear attracting addicts and potential robberies if their round-the-clock availability is publicized. The problem is only further complicated by the fact that there is very little communication about a patient between physician and pharmacist other than the prescription itself.
The voluminous documentation that resulted from the hearings was carefully studied by the members of the Special Subcommittee. It has been used as the basis for this report which is directed to acute and terminal pain. This final report includes recommendations, regulatory changes, and proposed new legislation.
In addition, the Special Subcommittee has studied the activities of other states concerning pain management. Pain Commissions have been established and reports have been filed in California, Arkansas, Florida and Georgia. None of these states has followed up with legislation. There is legislation pending in Texas as well as a regulatory change approved in that state (copies of the efforts in Texas may be found in Supplement C.)
Summary of Recommendations, Regulations and Legislation of the Special Subcommittee on the Management of Acute and Terminal Pain
Issue: Reinforcement of Optimal Pain Management Techniques
- Use existing standards from the American Pain Society for the treatment of pain ( see Supplement D).
- Encourage health care providers to include pain as an appropriate vital sign in patient evaluations.
- Encourage all health care providers to treat pain aggressively.
- Facilitate better communication between various professional organizations and agencies involved in the treatment of pain.
- Request the Department of Public Health facilitate periodic meetings of appropriate regulatory agencies, professional organizations and others to work towards improved pain management in the Commonwealth;
- Request the Department of Public Health adopt by policy the American Pain Society guidelines and disseminate to appropriate health care providers and organizations;
- Encourage adoption of the American Pain Society guidelines by the Health Care Financing Administration, Joint Commission, Medicare and state licensing authorities for all health care institutions and ambulatory services; and
- Request the Department of Public Health and other appropriate state agencies to develop a list of existing informational materials and audiovisual aids on pain management techniques for patients' use or, where necessary, to develop supplemental materials.
Issue: Patients' Rights
- Require notification of type and range of pain management benefits.
- Include Pain Management as a Patient Right.
- The Special Sub-Committee shall formally endorse legislation which focuses on patients' rights such as An Act to Protect Patients, filed in 1995 by Representative David Cohen (D-Newton) (see Supplement E). Representative Cohen's bill has been refiled for consideration during the 1997-98 legislative session;
- Request the Department of Public Health to disseminate materials to appropriate organizations on the availability of research protocols to assist in the treatment of pain; and
- Request the Department of Insurance have insurers provide notification of type and range of pain management benefits to policy subscribers.
Issue: Removal of Barriers to Coverage of Pain Management
- Establish clear legal protection for chronic opioid use when medically appropriate.
- Assure appropriate and trained personnel serve as case managers for claims involving pain treatments. Incorporate monitoring of pain into formal discharge plans at licensed health care facilities.
- Request the Department of Public Health to examine current discharge protocols to incorporate language pertaining to pain management;
- Request the Division of Insurance to require insurers to designate appropriate personnel, adequately trained in pain management, to serve as case managers for claims involving pain treatments; and
- Request the Division of Insurance to require that psychological consultations requested as part of pain management treatment be classified as a medical benefit rather than a mental health benefit.
- Include Pain Management as part of the Risk Management category of Continuing Education credits for physicians, nurses, and pharmacists.
- Encourage healthcare professional organizations to promulgate the findings of the Special Sub-Committee on Pain Management.
- Encourage Medical, Nursing and Pharmacy Schools to examine issue of preparing health care providers with adequate knowledge of pain management techniques.
- Encourage public education and advocacy for consumer interests.
- Request the Department of Public Health to coordinate a meeting with appropriate health care regulatory boards to discuss the findings of the Special Sub-Committee on Pain Management and to solicit support;
- Request the Division of Registration and the Board of Registration in Medicine to meet with appropriate health care regulatory boards and professional organizations to discuss expansion of knowledge of pain management techniques;
- Request a modification in the Board of Registration in Medicine's regulations to include Pain Management as part of Risk Control category of Continuing Medical Education Credits;
- Request a modification in the regulations of the Boards of Registration in Nursing, Pharmacy and Physician Assistants to require a minimum number of contact hours in pain management biannually;
- Request appropriate health care regulatory boards require their licensees to properly notify patients of their right to receive adequate treatment for pain and to conduct appropriate assessments for pain;
- Request that the Deans of Massachusetts-based schools of medicine, nursing and pharmacy provide copies of their curriculums dealing with pain management, and upon receipt of such reports, the University of Massachusetts Medical School shall convene a round table discussion with these schools to seek better approaches in preparing health care professionals with adequate knowledge of pain management techniques;
- The Special Sub-Committee will provide various professional organizations and journals with copies of the Report of the Special Subcommittee on Pain Management for publication;
- Request the New England Pain Society and other appropriate pain associations compile a listing of available treatment modalities as well as a resource list of pain clinics for distribution to the American Pain Society, health care providers, senior citizens centers, patient advocacy groups, insurers, the media and other appropriate organizations which, in turn, should be made readily available to the public; and
- Request the New England Pain Society and other appropriate pain associations organize a speakers bureau, comprised of health care professionals, consumers and others who are knowledgeable on the issue of pain management.
Issue: Licensing Standards for Pain Management Providers
- Use the IASP/AHCPR guidelines for clinic and physician certification (see Supplement F). Examine existing licensing standards through the Department of Public Health.
- Request the Department of Public Health examine licensing standards for programs, centers and other similarly named entities involved in the treatment of pain and make appropriate recommendations to the Joint Committee on Health Care;
- Encourage adoption of the American Pain Society guidelines by appropriate health care regulatory agencies and Massachusetts-based professional organizations; and
- Request the Division of Registration and the Board of Registration in Medicine convene a meeting with appropriate health care regulatory agencies to discuss standards and credentials for health care practitioners and other allied health professionals involved in the treatment of pain.
- Increase outreach and education programs for pharmacists in conjunction with appropriate professional organizations. Use the list of twenty-four hour pharmacies developed by the Board of Registration in Pharmacy. Update Massachusetts statutes pertaining to pharmacies filling prescriptions for pain medications.
- Amend M.G.L. Chapter 94C, s. 1 to include facsimiles under the definition of written prescription (see Appendix A);
- Amend M.G.L. Chapter 94C, s. 18(d) to allow Massachusetts-based pharmacies to fill prescriptions for Schedule II drugs from out of state and beyond contiguous states (see Appendix B);
- Amend M.G.L. Chapter 94C, s. 23(a) to permit the filling of a Schedule II prescription within 30 days after the prescription was written (see Appendix C);
- Amend M.G.L. Chapter 94C, s. 20(c) to permit an oral Schedule VI prescription without written follow-up (see Appendix D);
- Amend M.G.L. Chapter 94C by striking out s. 24, a section which requires physicians to report the names of patients who are being treated for their addiction to the Bureau of Substance Abuse within the Department of Public Health (see Appendix E);
- Request the Department of Public Health, the Division of Registration and the Board of Registration in Medicine to initiate a discussion with professional associations, health care regulatory agencies and state and federal law enforcement agencies to develop improved methods to verify the validity of prescriptions for pain medications;
- Request the Department of Public Health to engage in ongoing discussions with the Board of Pharmacy to facilitate ways to improve access to pain medications by consumers throughout the state;
- Request the Board of Pharmacy to maintain a current listing of all 24-hour pharmacies operating in the state and to make such list available to the public; and
- The findings, recommendations and actions plans of the Special Subcommittee on Pain Management will be published in Pharmacy Update, which is distributed to all Massachusetts licensed pharmacists as well as industry representatives.
Pain is one of the most common reasons consumers seek medical attention. Yet, as the Special Subcommittee on the Management of Acute and Terminal Pain heard repeatedly in its hearings, pain is frequently undertreated, leaving consumers to suffer needlessly and their families with a sense of helplessness. Misperceptions and fears about pain medications, including the potential risk of criminal charges, tolerance to the medication, and their addictive potential are common causes of undertreatment and reasons for noncompliance by health care professionals as well as consumers.
While much has been said about the need to recognize consumers' rights in the area of pain management, the converse must also be emphasized. If a consumer has rights, that consumer also has responsibilities. No effective pain management approach can be successful if the responsibilities are only assumed by health care professionals.
As Francis S. Campion, M.D., Vice President for Clinical Integration at the Caritas Christi Health Care System commented in his written testimony before the Special Sub-Committee on the Management of Acute and Terminal Pain on June 11, 1996:
"Legislators and public health leaders have a critical role to play in the improvement of pain management services in the Commonwealth of Massachusetts.... I believe that we are truly on the verge of dramatically improved pain management services for our citizenry. More work lies ahead. We seek your partnership to begin a public education campaign on the issues of pain management and palliative care. We need your leadership to foster a legal and health insurance environment which recognizes the uniqueness and protects the dignity of each of our people."
The issues that have been raised in this report will be circulated to concerned organizations and individuals. In addition, legislation has already been prepared and
filed for consideration during the 1997-98 legislative session. (see Supplement G).
It should be noted that this report to the legislature with its numerous recommendations, proposed regulations and legislation is but a first step in a work in progress. It is a starting point in identifying the issues raised in public forums across the state and in seeking to encourage regulatory agencies and professional health care organizations to address these problems. Effective pain management can not occur through legislation alone or even primarily. Rather, it will be health care professionals working together who will arrive at the creative answers needed for the complex questions that are asked in this report and the work that will be required for the issue of chronic pain.